What is the initial approach to treating vertigo?

Initial Approach to Treating Vertigo

The initial approach to vertigo depends critically on distinguishing peripheral from central causes through timing and triggers, followed by targeted physical examination maneuvers—with canalith repositioning procedures as first-line treatment for BPPV (the most common cause), while avoiding routine vestibular suppressant medications. 1, 2

Step 1: Classify by Timing and Triggers

The American Academy of Otolaryngology-Head and Neck Surgery recommends classifying vertigo into vestibular syndromes based on temporal patterns before initiating treatment 3:

• Triggered episodic (<1 minute): Episodes provoked by specific head position changes suggest BPPV, superior canal dehiscence, or perilymphatic fistula 3
• Spontaneous episodic (minutes to hours): Unprovoked episodes lasting 20 minutes to hours suggest Ménière's disease, vestibular migraine, or vertebrobasilar insufficiency 3
• Acute vestibular syndrome (days): Continuous severe vertigo lasting days suggests vestibular neuritis, labyrinthitis, or posterior circulation stroke 3
• Chronic (weeks to months): Persistent symptoms suggest anxiety disorder, medication effects, or posterior fossa mass 3

Step 2: Identify Red Flags Requiring Urgent Imaging

Before treating as peripheral vertigo, exclude central causes that require immediate MRI. The following findings mandate urgent MRI brain without and with IV contrast rather than empiric treatment 2, 3:

• Positive Romberg test (indicates central pathology—do NOT perform Dix-Hallpike until imaging excludes central causes) 2
• Severe postural instability 3
• Cranial nerve deficits 3
• Age >50 with vascular risk factors 3
• HINTS examination abnormalities: nystagmus changing direction without head position changes, downward nystagmus in Dix-Hallpike, vertical skew deviation, or normal head impulse test 2

Critical pitfall: Up to 75-80% of posterior circulation strokes causing vertigo lack focal neurologic deficits initially, and CT head misses posterior fossa strokes in the acute phase 2, 3

Step 3: Diagnose BPPV with Specific Maneuvers

For triggered episodic vertigo without red flags, perform diagnostic maneuvers 1:

• Dix-Hallpike maneuver: Bring patient from upright to supine with head turned 45° to one side and neck extended 20°, looking for torsional upbeating nystagmus (posterior canal BPPV—most common type) 1
• Supine roll test: If Dix-Hallpike shows horizontal or no nystagmus but history compatible with BPPV, perform supine roll test to assess for lateral canal BPPV (10-15% of cases) 1, 3

Step 4: Treat BPPV with Canalith Repositioning

For confirmed posterior canal BPPV, perform canalith repositioning procedure immediately—this is a strong recommendation with cure rates of 86-100% with up to 4 treatments. 1

Key treatment principles:

• Do NOT recommend postprocedural postural restrictions after canalith repositioning—this is a strong recommendation against their use 1
• Observation with follow-up may be offered as initial management, given BPPV's high spontaneous resolution rate 1
• Do NOT routinely treat with vestibular suppressant medications (antihistamines, benzodiazepines like meclizine or diazepam)—the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against this 1, 4

Step 5: Consider Vestibular Rehabilitation

Vestibular rehabilitation (self-administered or clinician-directed) may be offered as a treatment option for BPPV, particularly for vestibular hypofunction 1, 5

Step 6: Reassess Treatment Failures

Reassess patients within 1 month to document resolution or persistence of symptoms. 1 For persistent symptoms after initial treatment:

• Repeat diagnostic maneuvers to check for unresolved BPPV in the same or different canal 1
• Consider "canal conversion" (lateral to posterior canal or vice versa occurs in ~6% of cases) 1
• Evaluate for coexisting vestibular dysfunction, particularly in patients with history of head trauma, vestibular neuritis, Ménière's disease, or migraine 1
• CNS disorders masquerade as BPPV in 3% of treatment failures—maintain high suspicion for central causes 1

What NOT to Do

• Do NOT obtain radiographic imaging for patients meeting BPPV diagnostic criteria without additional inconsistent signs/symptoms 1
• Do NOT order vestibular testing for patients meeting BPPV diagnostic criteria without additional inconsistent vestibular signs/symptoms 1
• Do NOT treat empirically as BPPV when Romberg is positive—this indicates central pathology requiring imaging first 2
• Do NOT discharge without imaging when Romberg is positive with vertigo 2
• Do NOT rely on CT head as definitive imaging for vertigo with central warning signs 2